Citation Nr: 9914455
Decision Date: 05/24/99 Archive Date: 06/07/99
DOCKET NO. 94-36 822 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Cleveland,
Ohio
THE ISSUE
Entitlement to service connection for post-traumatic stress
disorder.
REPRESENTATION
Appellant represented by: Veterans of the Vietnam War,
Inc.
ATTORNEY FOR THE BOARD
Martin F. Dunne, Counsel
INTRODUCTION
The veteran served on active duty in the Armed Forces from
October 1968 to October 1972.
This matter comes before the Board of Veterans' Appeals
(Board) on appeal from a December 1993 rating decision by the
Department of Veterans Affairs (VA) Regional Office (RO) in
Cleveland, Ohio, which denied service connection for post-
traumatic stress disorder (PTSD). The veteran appealed that
decision to the Board.
The veteran was scheduled for a personal hearing to be held
in August 1994 at the RO. He was notified of the hearing,
but he did not appear at the appointed time and place. In
May 1996, the Board remanded the case to the RO for further
development, to include clarification of whether the veteran
still desired a personal hearing. The veteran notified the
RO in October 1996 that he no longer wished to appear at a
personal hearing. After completing the other development
requested in the remand, the RO subsequently denied the claim
and the case was returned to the Board for appellate
determination.
FINDINGS OF FACT
1. All relevant evidence necessary for the equitable
disposition of this appeal has been obtained by the RO.
2. Although the veteran does not contend, and his service
records do not clearly establish, that he engaged in combat
with the enemy, the RO has verified that, during service, the
veteran's base was subject to mortar/rocket attack, to
include on November 17, 1990.
3. Various medical records suggest that the veteran may have
PTSD; however, a VA examiner determined that the veteran did
not suffer from PTSD as a result of his verified in-service
stressor, and the record contains no medical diagnosis of
PTSD based upon the verified in-service stressor.
CONCLUSION OF LAW
The criteria for service connection for PTSD are not met.
38 U.S.C.A. §§ 1110, 5107(a) (West 1991); 38 C.F.R. §§ 3.303,
3.304(d)(f) (1998).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
I. Background
The veteran's entire active duty service was spent in the Air
Force. His military personnel records show that he had an
occupational specialty as an airplane mechanic, and that,
from January 1970 to November 1970, he was stationed in
Vietnam, specifically as a crew member, aircraft mechanic, of
a tactical fighter squadron that was assigned to Bien Hoa Air
Base. He was awarded the National Defense Service Medal, Air
Force Good Conduct Medal, Vietnam Service Medal, Republic of
Vietnam Campaign Medal, and Air Force Commendation Medal.
Following his separation from active duty, he found civilian
employment with the Air Nation Guard Bureau as a military
technician, and he was a member of the Air National Guard.
Essentially, the veteran maintains that he has a clinical
diagnosis of PTSD and that the sources of his disorder are
the memories of frequent rocket and mortar attacks on the air
base during which he had to hide in a bunker; of seeing dead
and wounded personnel following those attacks, and of viewing
the destruction which resulted from those attacks. He
specifically emphasized the rocket attack of November 17,
1970, during which several people were killed, as being
especially stressful.
A review of the veteran's service medical records shows that
he had no complaints, symptomatology or treatment for any
psychiatric pathology in service His October 1972 service
separation examination report indicates a normal psychiatric
evaluation.
Post-service, he underwent a VA medical examination in April
1973. No diagnosis of or findings pertaining to any
psychiatric disorder were then made.
Outpatient treatment records from an Air Force medical
facility, dated from February to July 1992, show treatment
for shortness of breath, dyspnea upon exertion, and chest
pain. However, none of these records reflect treatment for
an acquired neurosis.
In a September 1992 letter to the Department of the Air
Force, K. Blissenbach, M.D., the veteran's private treating
physician, related that the veteran was suffering from panic
attack disorder and chronic anxiety. The physician also
related that the chronic anxiety may be due to the veteran's
PTSD or a generalized anxiety disorder of a heredity basis.
It was the physician's opinion that the veteran was unable to
perform the duties of his employment due to his emotional
disorder.
In November 1992, the veteran underwent a fee basis VA
psychiatric evaluation during which he related that he served
on active duty as an Air Force mechanic during Vietnam and
that he was a combat veteran. He complained of emotional
problems, such as chronic anxiety, phobia, fear of crowds and
open space, and he also believed that he was suffering from
PTSD with nightmares and flashbacks. According to the
veteran, he was experiencing those symptoms for over five
years and that he was being treated by a private psychiatrist
who diagnosed generalized anxiety and panic attack with a
possible diagnosis of PTSD. The veteran claimed he had
difficulty handling loud noise and that he was having
difficulties coping with day-to-day stress. On examination,
the diagnosis was generalized anxiety with panic attacks.
Also, the examiner noted that the veteran had some symptoms
suggestive of PTSD; however, mild in nature.
The veteran was administratively discharged from the Air
Force Reserves in January 1993 on the basis that he did not
meet the physical requirements for retention. The Air Force
Reserve Medical Board found him medically disqualified for
worldwide duty because of asthma, allergic rhinitis,
anxiety/panic disorder, and chronic anxiety.
The veteran underwent psychological testing in September
1993. The psychologist noted that the veteran's profile was
partially typical for a Vietnam veteran with PTSD, but that
he also had other compounding features. He related that the
best possible diagnoses to be considered were obsessive-
compulsive disorder, PTSD, dysthymia, secondary to PTSD, and
somatoform disorder, not otherwise specified.
In a letter dated in October 1993, Dr. Blissenbach related it
was his impression that the veteran suffered from PTSD, in
addition to anxiety attack disorder and generalized anxiety.
He further related that the veteran's PTSD concerned
traumatic events that occurred while he was in Vietnam and
included typical symptoms of hypervigilence, flashbacks,
nightmares, trouble sleeping, generalized anxiety, and
dysphoria.
The veteran underwent a privately administered Minnesota
Multiphasic Personality Inventory (MMPI) test in January 1994
which showed anxiety, depression, and some obsessive
compulsive features in his thinking. The psychologist noted
that the veteran reported having several stressful things
occur in his life, including a tour of duty in Vietnam, which
gave him flashbacks from time to time. Although the veteran
admitted that he did not do active face-to-face combat duty
in Vietnam, he recognized that the constant fear of attacks,
sniper fire, and danger that he lived within was sufficient
in causing his current PTSD and constant anxiety. The
psychologist also noted that the veteran's performance on the
MMPI revealed a markedly elevated profile, which made
validity highly suspect. The suggestion was that the veteran
over exaggerated his symptoms, which was consistent with the
clinical interview, or that his response pattern was one of
random responding or systematic item avoidance - both of
which the veteran denied. The test results showed extreme
anxiety, dependency, depression, anger, hypersensitivity,
paranoia, some schizophrenic or dysfunctional cognitive
processes, psychomotor acceleration with ego inflation, and
extreme discomfort around others or social introversion. He
continued to suffer from poorly developed interpersonal
skills, which made him more introverted and less confident in
group situations. He continued to use repression as one of
his defense mechanisms. The diagnoses were 309.89
(PTSD)/300.30 (Obsessive-Compulsive Disorder).
The VA received a letter dated in May 1994, signed by
[redacted] and the veteran, in which Mr. [redacted] related
that he had served with the veteran in Vietnam during 1969
and 1970, and that while at Bien Hoa Air Base, they were
subject to random, and often intense rocket attacks. Also,
he related that they were, on several occasions, almost
overrun by communist forces. Mr. [redacted] further related
that, in November 1970, the bunker he was sleeping in took a direct
rocket hit and the veteran, who was out-processing to return
to the States, took cover in a bunker when the attack
occurred and that the bunker next to the one the veteran was
in received a direct hit, killing everyone inside. Mr.
[redacted] further stated that both he and the veteran saw many
dead and wounded. As proof of the claimed occurrence, Mr.
[redacted] submitted a copy of a November 17, 1970, report of
medical treatment for himself, showing complaints of ringing
in the ears after a rocket hit his barracks.
Information from the Social Security Administration shows
that the veteran was awarded disability benefits in October
1994, effective from July 1993. The bases given for the
award were the veteran's personality disorders (paranoid,
avoidant, dependent with obsessive-compulsive traits, panic
disorder with agoraphobia, dysthymia) and his back disorders.
The RO received the veteran's PTSD development sheet in
November 1994 in which he related that he did not have the
exact dates of the traumatic events that caused his PTSD, and
that the air base on which he was stationed was under
numerous rocket attacks; he particularly remembered the
attack of November 17, 1970. He admitted in the
questionnaire that he had never fired a weapon at the enemy,
nor had he ever seen anyone actually killed, although he
stated that he had seen bodies of those that had been killed.
He also supplied a couple of names of fellow servicemen who
had served with him in Vietnam.
In response to any RO inquiry, the Director of the United
States Armed Services Center for Research of Unit Records
(Unit Records Center), indicated, in a January 1997 letter,
indicated that an Air Force casualty report for November 17,
1970 confirmed specific deaths and injuries at Bien Hoa Air
Base on that date due to rocket/mortar attack.
After corroboration of mortar/rocket attack of the veteran's
base was received, as indicated above, the veteran underwent
VA psychological and psychiatric evaluations, in March and
April 1997 specifically to determine whether the veteran had
PTSD. In this regard, it was requested that review of the
veteran's claims file be accomplished, and that all
appropriate tests be conducted.
In March 1997, the veteran was administered another MMPI by a
VA psychologist who reviewed the veteran's claims file in
conjunction with the evaluation. The evaluation revealed
that the veteran was depressed; he mistrusted authority
figures; he spent a great deal of time in fantasy and
daydreaming; and he warded off close personal relationships
with others. The examiner found that the veteran was not a
socially skilled individual and the examiner also thought
that the veteran may have guessed at appropriate emotional
responses.
The report of the veteran's April 1997 VA psychiatric
examination notes subjective complaints of having phobia
while in the military. The veteran related that he was
afraid to be in the middle of a group and, if it happened, he
had to sit near the exit. He was afraid that something might
happen in such setting, such as "maybe the ceiling might
fall or there will be a loud noise," and if something did
happen, he would be able to leave. He further related that
his heartbeat would run fast and he would feel like he had a
red flush on his face. Sometimes he became dizzy and sweaty.
He claimed that he never went to July 4th celebrations
because there were too many people and because of the loud
noises. The veteran claimed that in his nightmares the enemy
captures him, he changes clothes, and the enemy makes him
fight on their side. He also claimed that his area was hit
by rockets and mortar lots of times. But, in his nightmares,
all the US servicemen are killed; yet he is never killed. He
also stated that, when he was in the middle of traffic one
time, he got scared, opened the door of his car, got out,
and, after a few minutes, was okay and he was able to come
back to his car. He further asserted that he was easily
startled by loud noises. He claimed that before he started
on medication, such as Xanax, he experienced cold sweats, but
not recently. He related that he did not sleep well, and
some times he felt like people were following or watching
him. Upon examination, he appeared alert. His affect was
slightly elevated, otherwise, he was appropriate. He was
calm and cooperative. His speech was coherent and relevant.
There were no hallucinations, but some paranoid ideation was
expressed. He was oriented to time, place, and person, and
his memory was intact. He denied suicidal or homicidal
ideation. In the examiner's opinion, the veteran able to
manage his own benefit payments. The physician had reviewed
the veteran's claims file in conjunction with the examination
and gave the diagnosis of generalized anxiety disorder. He
assessed the veteran as having a Global Assessment of
Functioning (GAF) scale score of 60, indicative of someone
with moderate difficulty in social or occupational
functioning.
II. Analysis
To establish service connection, the evidence must
demonstrate that a particular disease or injury resulting in
current disability was incurred during active service or, if
preexisting active service, was aggravated therein.
38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. As VA recognizes that
symptoms attributable to PTSD often do not appear in service,
service connection for PTSD requires: (1) a clear, current
medical diagnosis of PTSD; (2) credible supporting evidence
that the claimed in-service stressor actually occurred; and
(3) medical evidence of a causal nexus between current
symptomatology and the specific claimed in-service stressor.
See 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128
(1997).
In the case at hand, the veteran has presented a diagnosis of
PTSD made by his private physician and evidence that a VA
physician has found symptoms suggestive of PTSD; these
opinions are sufficient to well ground the claim. See
38 U.S.C.A. § 5107(b); Murphy v. Derwinski, 1 Vet. App. 78,
81 (1990). The question remains, however, as to whether the
veteran, in fact, has a credible diagnosis of PTSD when this
question is considered in light of the remaining criteria for
service connection for the condition: namely, credible
evidence that the claimed stressor(s) actually took place,
and of a nexus between the stressor and the veteran's
symptoms.
The evidence necessary to establish the occurrence of a
recognizable stressor during service to support a diagnosis
of PTSD will vary depending upon whether the veteran engaged
in "combat with the enemy," as established by recognized
military combat citations or other official records. See,
e.g., Doran v. Brown, 6 Vet. App. 283, 289 (1994); Hayes v.
Brown, 5 Vet. App. 60, 66 (1993).
If the VA determines the veteran engaged in combat with the
enemy and his alleged stressor is combat-related, then his
lay testimony or statement is accepted as conclusive evidence
of the stressors occurrence and no further development or
corroborative evidence is required - provided that such
testimony is found to be "satisfactory," i.e., credible,
and "consistent with the circumstances, conditions,
or hardships of service." See 38 U.S.C.A. § 1154(b); 38
C.F.R. 3.304(f); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993).
Here, the veteran does not specifically contend, and the
evidence does not clearly establish, that the veteran engaged
in combat during his Vietnam service. In Vietnam, he was
assigned as a crewmember, aircraft maintenance, of a tactical
fighter squadron that was stationed on Bien Hoa Air Base. As
an aircraft mechanic assigned to the air base, he normally
would not typically be associated with actual combat. His
military personnel records do not show that he engaged in
combat with the enemy, and his awards and decorations do not
include any specifically for combat service. Significantly,
during private psychological testing conducted in January
1994 he stated that he did not do active face-to-face combat
duty in Vietnam. Moreover, in his PTSD questionnaire, dated
in August 1994 and received by the VA in November 1994, he
related that he had never fired a weapon at the enemy nor had
he ever seen anyone actually killed, although he had seen
bodies of those that had been killed.
That notwithstanding, the fact that the veteran's base was
subject to mortar/rocket attack during his Vietnam service
(to include on November 17, 1990) has been corroborated by
both the Unit Records Center and the statement by [redacted],
the veteran's former service comrade. However, the record
does not contain a credible diagnosis that the veteran, in
fact, has PTSD as a result of such verified in-service
stressful experiences. In this regard, the Board notes that
neither Dr. Blissenbach's October 1993 diagnosis of PTSD, nor
the November 1992 VA physician's note that the veteran has
some symptoms suggestive of PTSD (assuming, for the sake of
argument, that this constitutes a diagnosis), includes
reference to a specific in-service stressful experience as
the basis for the diagnosis, and, thus, does not indicate how
the veteran's symptoms relate to any such stressor. The
Board is not bound to accept as credible a diagnosis of PTSD
that is not based upon a recognizable stressor. See Swann v.
Brown, 5 Vet. App. 229, 233 (1993). It is noted that, at the
time those opinions were rendered, no in-service stressful
experience had then been verified. Finally, the only medical
opinion rendered after the verification of the veteran's in-
service stressor is the report of the April 1997 examiner who
rendered an Axis I diagnosis of anxiety disorder, but did not
diagnose PTSD. The Board finds such opinion highly probative
on the question of whether there is credible medical evidence
that the veteran has PTSD as a result of his verified in-
service stressor since the diagnosis was based upon
consideration of the veteran's documented medical history and
was made in light of contemporaneous psychological testing.
Thus, the Board finds that the 1997 VA psychiatrist's
diagnosis of anxiety disorder clearly outweighs the diagnoses
of PTSD of record.
In determining whether a claimed benefit is warranted, VA
must determine whether the evidence supports the claim or
whether the evidence is in relative equipoise, with the
veteran prevailing in either event, or whether the
preponderance of the evidence is against the claim, in which
case the claim is denied. See 38 U.S.C.A. § 5107(a); Gilbert
v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Under the
circumstances of this case, the Board must conclude that the
preponderance of the evidence is against the veteran's claim
for service connection for PTSD. As such, the claim for the
benefits sought must be denied.
(CONTINUED ON NEXT PAGE)
ORDER
Service connection for PTSD is denied.
JACQUELINE E. MONROE
Member, Board of Veterans' Appeals